Hospital discharge is a complex process that requires patient and caregiver engagement in order to transpire safely. Interviews with members of a Canadian patient safety organization who had recently been discharged from the hospital revealed that they desired better communication as well as more attention to their social determinants of health. A PSNet perspective discussed interventions to improve safety during the transition from hospital to home.

Care transitions represent a vulnerable time for patients, especially at the time of hospital discharge. In this systematic review, researchers identified several factors related to discharge summaries that may adversely impact the safety of discharged patients, including delays in sending discharge summaries to outpatient providers as well as missing or low-quality information.

Journal Article > Study

Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.

Journal Article > Study

This mixed-methods study combined survey data from resident physicians with a comparison of process maps from three academic medical centers to assess handoffs from intensive care units to medical wards. The vast majority of survey respondents could recall at least one adverse event related to suboptimal handoff communication between these settings, and review of the process maps revealed safety gaps in existing processes.

Champions play critical roles for implementing change in organizations. This commentary reports the results of a program to train champions of the I-PASS handoff program. The initiative used a set of tools and educational tactics to build frontline leaders' skills to mentor standardized handoffs behaviors at 32 locations. The process and tools were considered by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions.

Journal Article > Study

Reporting complete patient information during clinical rounds is important for achieving an accurate diagnosis and informing clinical management. Prior research has shown that data is sometimes omitted or inaccurately communicated on rounds. This observational study compared patient data shared by trainees and medical students on ICU rounds to that contained within the electronic health record. Researchers analyzed photocopies of trainee and student notes as well as audio recordings of their oral presentations. For the 157 patient presentations included in the study, they found all contained data omissions and that other team members on rounds supplemented a minimal amount of data missing from student and trainee presentations. The authors recommend additional oversight and education of trainees with regard to data presented on rounds.

Cases & Commentaries

Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.

Journal Article > Study

This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.

Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.

Journal Article > Study

Provider inexperience and frequent handoffs create unique safety hazards in teaching environments. This multilevel modeling study investigated predictors of pediatric adverse events at children's hospitals. Investigators noted more adverse events under the following circumstances: earlier in the academic year (the July phenomenon), in hospitals offering more technically complex services, and in hospitals with a higher number of resident physicians for each patient. A PSNet perspective discussed the appropriate balance between autonomy and supervision for training physicians.

Cases & Commentaries

Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.

Journal Article > Study

Communication errors during handoffs can lead to patient harm. Standardizing the handoff process has been shown to improve patient safety. This prospective trial demonstrated that implementation of a standardized intensive care unit sign-out process among residents led to fewer unexpected patient events and unplanned interventions.

Journal Article > Study

Research suggests that standardization, dedicated space, and supervision improve resident handoffs, but less is known about how these best practices are implemented. Investigators surveyed residency program directors and found significant variation in the implementation of recommended handoff practices and educational strategies.

Cases & Commentaries

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

Journal Article > Commentary

Medical students and residents can benefit from learning communication skills early in their training. This commentary describes medical improvisation as a way to improve clinician listening behaviors, teamwork, communication, and empathy among clinicians.

Cases & Commentaries

Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.

Journal Article > Study

This prospective cohort study across three sites with an internal medicine residency program found no relationship between resident discontinuity and adverse events. Safe handoffs have become even more essential in the era of resident duty hour restrictions.

Journal Article > Study

This survey of academic intensivist physicians found that although most reported participating in end-of-shift handoffs, the handoff process varied across institutions. Satisfaction with handoff procedures was suboptimal, and a significant proportion of respondents could recall an adverse event related to handoffs. This suggests that despite extensive work in this area, handoffs remain a persistent safety vulnerability.

Journal Article > Commentary

Due to variability in handoff practices across teams, units, and organizations, the process is vulnerable to error. This commentary describes a standardized change-of-shift form designed to help improve nursing students' communication skills and clinical reasoning.